Anthem Blue Cross accused of 'fraudulent' enrollment practices

By Julie Appleby Kaiser Health News

Posted:
07/09/2014 05:49:44 AM PDT

Updated:
07/09/2014 07:30:08 AM PDT

LOS ANGELES -- California insurance giant Anthem Blue Cross misled "millions of enrollees" about whether their doctors and hospitals were participating in its new "Obamacare" plans and failed to disclose that many policies wouldn't cover care outside its approved network, according to a class-action lawsuit filed Tuesday.

As a result, many consumers are on the hook for thousands of dollars in medical bills and have been unable to see their longtime doctors, alleges the suit filed in Superior Court in Los Angeles by Santa Monica-based Consumer Watchdog. While declining to comment on the suit, Anthem has conceded that some doctors were inaccurately listed on its plans.

Brought on behalf of Anthem enrollees who purchased individual coverage between Oct. 1, 2013 and March 31, 2014, the lawsuit reflects growing consumer push-back against so-called "narrow network" health plans, which are increasingly common under the Affordable Care Act, commonly known as Obamacare. Anthem is a major player on California's health insurance exchange, and the suit includes those who bought coverage online, as well as directly from the insurer.

The suit says that Anthem, the state's largest individual health insurer, delayed providing full information to consumers until it was too late for them to change coverage. The suit also alleges that Anthem failed to disclose it had stopped offering any plans with out-of-network coverage in four of the state's biggest counties -- Los Angeles, Orange, San Francisco and San Diego.

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Anthem spokesman Darrel Ng said that Anthem has agreed to pay the claims of those who received treatment from inaccurately listed doctors during the first three months of the year. However, he said, that policy would not be extended for enrollees who discovered after March 31 that their doctors had been incorrectly listed.

Anthem "intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share," said Jerry Flanagan of Consumer Watchdog.

The suit comes as the consumer advocacy group is pushing a measure on the November ballot that would give the state's insurance commissioner greater authority to veto health insurance rate increases.

Insurers have defended plans with limited provider networks as a way of holding down premiums. Surveys have indicated that many younger and healthier customers are willing to give up broad access to providers for lower costs.

But consumers are retaliating with lawsuits and complaints to state regulators. As a result of the rising complaints, state managed care regulators are investigating whether Anthem and Blue Shield of California provided accurate information about the doctors and hospitals in their plans.

The Consumer Watchdog lawsuit names six Californians who purchased Anthem plans. Among them is a Pasadena physician, Betsy Felser, who had coverage with Anthem for 20 years. Like hundreds of thousands of Anthem customers, she received a letter late last year stating that her preferred provider organization (PPO), which allows for in- and out-of-network care, was being canceled, according to the lawsuit. The letter suggested a replacement Anthem plan "with the benefits you have come to count on."

Before agreeing to switch, Felser said she checked with five Anthem telephone representatives, making it clear she wanted to be in a PPO.

"I would never have gotten anything that wasn't a PPO plan," said Felser, 47, whose insurance also covers her young son. "They said they would give me the same coverage."

During those calls, none of Anthem's representatives told Felser that the insurer was no longer offering PPOs in Los Angeles County, the lawsuit alleges. Nor did they tell her that the Anthem plans offered in her area would not cover care provided by out-of-network doctors or hospitals, according to the lawsuit.

Los Altos Hills residents Steven and Kathleen Moore were "fraudulently induced" into buying a Blue Cross "no deductible plan" that purported to include the family's regular physicians, the suit says. In actuality, the suit adds, the plan imposed a $10,000 deductible for out-of-network providers and none of the physicians were included in the new limited network.

Fred Crary, of San Jose, a longtime but now former Anthem Blue Cross customer, said he's not a fan of lawsuits. "But this is so important to families that I think it's a good step that (Consumer Watchdog) is taking," said the 59-year-old retired Silicon Valley tech executive.

Crary said Anthem "disenfranchised" people like himself and his wife after they discovered that their doctors would not accept their new Anthem plan, even after he said an Anthem representative had told him that his family's doctors were on the new plan's list of providers.

"I had no reason to believe they would not tell me the truth," said Crary, who has since switched his plan to HealthNet, a similarly priced plan that most of his doctors accept.

The same thing happened to Therese Meuel after the Moraga mother signed her daughter up for an Anthem plan because she was told the girl's pediatrician would accept the plan.

"They were very vague," Meuel recalled when she asked an Anthem representative about how she could confirm that to be the case. She said the representative advised her to both check Anthem's provider list and call the doctor's office to be sure. Both sources confirmed the pediatrician was on the list. But a few months later, when she made an appointment with the pediatrician -- who has taken care of her 17-year-old daughter since she was born -- the office told her the doctor was not accepting her daughter's plan.

Meuel supports the lawsuit, saying she hopes it "will get Blue Cross to get more doctors signed up on their list here." She too has since switched her daughter to a different plan, offered by Blue Shield of California, that her pediatrician accepts.

Staff writer Tracy Seipel contributed to this report. Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.